Provider Demographics
NPI:1912345323
Name:PEPPER, BROOKE N (AT, PTA)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:N
Last Name:PEPPER
Suffix:
Gender:F
Credentials:AT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 TRAIL E
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-9694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4850 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-3194
Practice Address - Country:US
Practice Address - Phone:641-566-0929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08358225200000X
OH0027612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer